Maryland Non-Gaming Vendor applicants Pay Careful ... · If a Vendor has three contracts, one at...

Maryland Lottery and Gaming Control Commission Vendor Certification Application Form # 1021

Form – 1021 (Rev October 4, 2017) Page 0 of 20 Initials_________________

Maryland Non-Gaming Vendor applicants

Pay Careful Attention to the Following: Vendor applicants must complete specific steps before submitting an application to the Maryland Lottery and Gaming Control Commission. Applications received with any of the four (4) following defects will cause significant delays in the processing of the vendor’s request for approval and may result in the disqualification of a vendor. The denial of an application will permanently prohibit the vendor from conducting any business with any Maryland licensed casino. 1) All vendors must obtain a ‘Casino’s Certification of Business Relationship’ form page.

Certification for pages can only be issued by a licensed Maryland casino or by designated casino construction companies authorized to issue certifications. A vendor applicant is prohibited from completing the ‘Casino’s Certification of Business Relationship’ form page. Certification form pages bearing the signature of a vendor applicant may be considered a material misrepresentation to the Commission, and may result in an automatic disqualification.

2) All vendors must register with the Maryland State Department of Assessments and

Taxation (MD SDAT) and submit verification of their compliance with MD SDAT regulations to the Commission. MD SDAT will determine whether the vendor is required to either:

A. File for and maintain “Good Standing” (the vendor is required to furnish the Commission with a copy of the ‘Certificate of Good Standing’ with the Vendor Form application); or

B. File for a “Trade Name Registration”. 3) All vendors must submit the required application Fee. Instructions for original / initial and

‘Upgrade’ applications are found in Section ‘C’, and the non-refundable fee is either $100 or $1,000. Instructions for Renewal applications are found in Section ‘D’, and the non-refundable fee is either $100 or $500. The application fee (except Wire Transfers) must be submitted with this application.

4) All vendors must submit accurate, legible and complete applications on single-sided pages.

Vendor applicants should carefully read all of the instructions and thoroughly review the entire document before submitting it to the Commission. Failure to submit required information may result in denial of an application. Refusal to rectify deficiencies following notification, or submission of false or misleading information, will result in the denial of an application.



Lottery and Gaming Control Commission

1800 Washington Boulevard, Suite 330, Baltimore, MD 21230

NON-GAMING VENDOR

CERTIFICATION APPLICATION

Form #1021

Vendor’s Business Name (Applicant): ________________________________________ This name MUST match the name registered with MD SDAT To be completed by the Vendor Applicant

Enter ‘D/B/A’ or ‘T/A’ name, if applicable: ___________________________________ To be completed by the Vendor Applicant

Casino –or- Casino Construction Company: ____________________________________ To be completed by the Vendor Applicant

MD SDAT Compliance Attached: Certificate of ‘Good Standing’ or ‘Trade Name Registration’ Circle one

Date submitted to MLGCC: ________________________________________________ To be completed by the Vendor Applicant

(This box is for MLGCA Use Only)

Vendor # V ________________________

Status: Initial / New Renewal *UPGRADE*

MD SDAT Department ID # _________________________________________

Application approval date: __________________________________________

Application approved by / title: _______________________________________

Payment: Wire Money Bank, Business, Cashier’s or Transfer Order Certified Check # _______________________



ACKNOWLEDGEMENT and CHECK LIST

The Vendor Applicant (“Applicant”), or the authorized Representative of the Applicant (refer to F.9), must

complete, sign and submit this ‘Acknowledgement and Check List’.

I, ______________________________, the Applicant, or the authorized Representative of the Applicant, have

thoroughly read Sections ‘A’ through ‘G’. I understand that the Applicant is under a continuing obligation to

promptly provide written notification of any changes in the information provided to the Commission

(including any individual listed herein as an Owner, Officer, Partner, Director, or Employee; physical/email

addresses; or phone numbers) whether in the application or on any material(s) submitted with or subsequent to

the application. (Signature) ________________________

I, ______________________________, the Applicant, or the authorized Representative of the Applicant,

declare and affirm that the information I am submitting to the Commission is accurate and correct, I am not

failing to disclose any material information relevant to this application and I am not submitting false or

misleading information. (Signature) ________________________

1) I checked the “APPROVED VENDORS” list to ensure that the Applicant is not already approved.

( http://gaming.mdlottery.com/licensing/approved-vendors )

No, we are not listed as an approved Vendor.

Yes we are listed, but this application is an *Upgrade*. (initials) __________

2) The Applicant’s Business Name is listed exactly as it is registered with MD SDAT. (initials) __________

3) The Applicant has registered with the Maryland Department of Assessments and Taxation (MD SDAT) and

has attached verification (Certificate of ‘Good Standing’ or ‘Trade Name Registration’) (initials) __________

4) The ‘Business Relationship Form’ (Page 19) has been signed by a Casino Representative or an Authorized Casino

Construction Representative only. The Vendor Applicant is not authorized to sign the form. (initials) __________

5) The Applicant has disclosed all officers, partners, directors and owners (Pp. 12 & 13). (initials) __________

6) The Applicant has disclosed all supervisory and management employees (Page 14), as described in H.9.

(initials) __________

7) The Commission deems every response to be mandatory, therefore each space (all 15 blocks per person) has

been accurately completed for every individual listed on this application (Pp. 12, 13, 14). (initials) __________

8) One ‘Authorization for Release of Information’ (Page 16) was completed and Notarized for each individual

included on this application, and each form was submitted with this application. (initials) __________

9) One ‘Authorization for Release of Information’ (Page 20) was completed and Notarized for the Vendor

Applicant’s business entity, listing the ‘Business Name’ on the ‘From’ line. (initials) __________

10) The ‘Affidavit of Representative of Vendor Form’ (Page 17) was completed, Notarized and submitted with

the application and each page has been initialed by the Vendor Representative. (initials) __________

11a) The application fee is attached to this application; or (initials) __________ or N/A __________

11b) The application fee was sent via Wire Transfer, and transmission was confirmed before submitting this

Application to the Commission. (initials) __________ or N/A __________

http://gaming.mdlottery.com/licensing/approved-vendors



SECTION A - REGULATIONS

A.1 A “Vendor” is any person who provides non-gaming related goods and services to a video lottery operation

licensee (Maryland licensed casino) or video lottery operation license applicant (applying to become a

Maryland licensed casino). A Maryland non-gaming Vendor:

a) Includes suppliers of alcoholic beverages; suppliers of food and non-alcoholic beverages; refuse

handlers; vending machine providers and service personnel; janitorial and maintenance companies;

tenant businesses or franchises located within casinos if such goods and services are not gaming

related; providers of transportation services if such services are not gaming related; persons involved in

the construction of a casino; lessors of real property or goods; payroll services and other employer

related services; employee recruiting services; or

b) Is a person whose services the Commission determines must be registered or certified; and

c) Is prohibited from providing or attempting to provide any gaming related goods, services or supplies

unless licensed by the Commission as a Gaming Manufacturer or Gaming Contractor.

A.2 Pursuant to Code of Maryland Regulation (COMAR) 36.03.02.17, a Vendor, unless exempt, is required to

be Registered or Certified with the Commission prior to conducting any business with a licensed casino

or casino license applicant.

SECTION B - APPLICATION CLASSIFICATION

B.1 A Vendor must determine the correct form based on the combined total value of non-gaming related

goods and services provided to, or anticipated to be provided to, a licensed casino or casino license

applicant within a calendar year.

B.2 A Vendor that provides, or anticipates providing non-gaming related goods and services within a calendar

year with a combined total value:

a) Of less than $9,999 is exempt from submitting an application to the Commission;

b) From $10,000 to $299,999 to a single casino or casino license applicant is required to be Registered by

the Commission;

c) From $10,000 to $599,999 to multiple casinos or casino license applicants is required to be Registered

by the Commission (unless at or above $300,000 to a single casino or casino license applicant, in

which case the Vendor must be Certified by the Commission);

d) At or above $300,000 to a single casino or casino license applicant is required to be Certified by the

Commission; or

e) At or above $600,000 to multiple casinos or casino license applicants is required to be Certified by

the Commission.



Examples of the requirements above are:

If a Vendor has three contracts, one at Casino ‘A,’, one at Casino ‘B’ and one at Casino ‘C’, each for

$190,000, the Vendor is required to be Registered by the Commission, since none of the contracts is above

$300,000 and the combined total value ($570,000) is under $599,999.

If a Vendor has three contracts, one at Casino ‘A,’ for $350,000, one at Casino ‘B’ for $110,000 and one

at Casino ‘C’ for $110,000, the Vendor is required to be Certified by the Commission, since one of the

contracts is above $300,000 even though the combined total value ($570,000) is under $599,999.

B.3 The Commission monitors the licensed Maryland casino’s payments to each vendor. If it is determined

that a Vendor’s combined total value of non-gaming related goods and services is approaching the

prescribed threshold, the casino may delay or cease payments to prevent a violation of Gaming

regulations. If it is determined that a Vendor’s combined total value of non-gaming related goods and

services has exceeded the prescribed threshold, the casino is required to cease payments.

If a Vendor, approaching the prescribed threshold, anticipates providing non-gaming related goods and

services which have a combined value exceeding the threshold, the Vendor is required to submit the

correct classification of application to the Commission. The Vendor is prohibited from conducting

business which will exceed the threshold until the Commission approves the Vendor’s application.

If a Vendor has exceeded the prescribed threshold, the Vendor is required to submit the correct

classification of application to the Commission. The Vendor is prohibited from conducting any further

business until the Commission approves the Vendor’s application.

Violations of Gaming regulations related to the combined total value of non-gaming related goods and

services provided by a Vendor may result in penalties or sanctions.

SECTION C - APPLICATION TYPE

C.1 Construction based vendors. Construction based vendors provide, or anticipate providing, non-gaming

related goods and services during the construction phase of the casino. This includes construction

management, general contractors and subcontractors.

C.2 Non-construction based vendors. Non-construction based vendors provide, or anticipate providing, non-

gaming related goods and services for the duration of the gaming and hospitality phase.

C.3 The Commission provides the casinos with an Emergency Usage of Non-Approved Vendor Services

declaration, Form 1024. A prospective Vendor does not complete the form. The form is completed and

submitted by a casino if a casino encounters an emergent threat to public health, safety, or welfare that is

outside its control and requires immediate provision of goods or services by a vendor. The casino is

required to submit the Form 1024 to the Commission no later than the next State business day.

C.4 Following a casino’s submission of a Form 1024 declaration to the Commission:

a) Unless exempt, a Vendor that provided services or goods as an emergency services response vendor,

valued from $10,000 to $299,999, whether during the construction phase or during the gaming and



hospitality phase, the Vendor is responsible for submitting a Vendor Registration Form, Form 1023 to

the Commission within 20 business days;

b) Unless exempt, a Vendor that provided services or goods as an emergency services response vendor,

valued at or above $300,000, during the construction phase, the Vendor is responsible for submitting a

Vendor Certification Form, Construction Version, Form 1021CC to the Commission within 20

business days;

c) Unless exempt, a Vendor that provided services or goods as an emergency services response vendor,

valued at or above $300,000, during the gaming and hospitality phase, the Vendor is responsible for

submitting a Vendor Certification Form, Form 1021 to the Commission within 20 business days.

C.5 Construction based vendor applicants should refer to the chart below to determine that the correct form

is submitted:

If a construction based vendor provides or anticipates providing in a calendar year the following amounts related to non-gaming goods and services:

Submit Form # Initial Fee

$9,999 and below Exempt, none $ 0

from $10,000 to $299,999 at a single casino 1023 $100

from $10,000 to $599,999 at two or more casinos Refer to B.2(c) 1023 $100

above $300,000 at any casino 1021CC $1,000

above $600,000 at two or more casinos 1021CC $1,000

C.6 Non-construction based vendor applicants should refer to the chart below to determine that the correct

form is submitted:

If a non-construction based vendor provides or anticipates providing in a calendar year the following amounts related to non-gaming goods and services:

Submit Form # Initial Fee




above $300,000 at a single casino 1021 $1,000

above $600,000 at two or more casinos 1021 $1,000

SECTION D - TERM OF REGISTRATION, TERM OF CERTIFICATION,

RENEWALS

D.1 Term: A Maryland non-gaming vendor’s registration or certification is valid for five years from the

date of approval.

D.2 Renewal Process: The Commission may renew the non-gaming vendor’s registration or certification

if the Vendor:



a) Submits an application for renewal to the Commission at least 90 days before the vendor’s registration

or certification expires, but not more than 120 days before the vendor’s registration or certification

expires;

b) Continues to comply with all vendor registration or certification requirements; and

c) Pays the vendor’s registration renewal or certification renewal fees listed below:

If a construction based vendor provides or anticipates providing in a calendar year the following amounts related to non-gaming goods and services:

Submit Form # Renewal Fee




above $300,000 at a single casino 1021CC $500

above $600,000 at two or more casinos 1021CC $500

If a non-construction based vendor provides or anticipates providing in a calendar year the following amounts related to non-gaming goods and services:

Submit Form # Renewal Fee




above $300,000 at a single casino 1021 $500

above $600,000 at two or more casinos 1021 $500

SECTION E - REMITTANCE OF FEES

E.1 Vendor application fees, made payable to “Maryland Lottery and Gaming Control Agency”, are due at the

time of application. The fees may be sent as a certified / bank check, money order or as a wire transfer.

Application fees are non-refundable.

E.2 Unless the Vendor applicant is paying via wire transfer, the Vendor should send the application and the

payment together to: Maryland Lottery and Gaming Control Agency

Attn: Casino Licensing and Background Investigation Division

1800 Washington Blvd, Suite 330

Baltimore, Maryland 21230

E.3 If the Vendor applicant chooses to send the fees via a wire transfer, payments are made as follows:

a) The Maryland Lottery and Gaming Control Agency Account Number is: 446014266944

b) The Name of the Account is: Maryland Lottery VLT Escrow 026009593

Bank of America, New York, NY

c) If necessary, SWIFT code is: BOFAUS3N Ref: Bank of America in the State of Maryland.



SECTION F - IMPORTANT NOTICES

F.1 This form is an official document of the Commission, and may not be altered or changed, except to

insert the information that is required. Any alteration or change to this document is prohibited and

may cause the application or the Vendor’s certification to be delayed or denied.

F.2 An Applicant must make accurate statements and include all material facts. Failure or refusal to provide

any required information; intentional omissions of material facts; misrepresentation of details; or failure or

refusal to meet any other requirement as set out in law or regulation may result in the denial of the

application. False or misleading statements to the Commission may subject a Vendor applicant to civil

and/or criminal penalties. All submissions are subject to verification.

F.3 The Commission's decision to deny or cancel a vendor registration or vendor certification, or denial of the

renewal of a vendor registration or vendor certification, does not give rise to an appeal right under the

contested case provisions of the Maryland Administrative Procedure Act.

F.4 A Vendor applicant is under a continuing obligation to promptly disclose any changes in the information

provided to the Commission (including any individual listed herein as an Officer, Partner, Director,

Employee or Owner; physical/email addresses; or phone numbers) whether in the application or on any

material(s) submitted. The Applicant shall provide written notification of any change(s). The duty to

inform the Commission is in effect from the date the application is submitted and continues through the

entire period the vendor registration or certification is granted.

F.5 If a Vendor changes the name of the company with which it conducts business with a licensed Maryland

casino or casino license applicant, the Vendor must submit a new Vendor Registration or Vendor

Certification application. The Vendor will list all the changes in name, address, contact information

etcetera, as well as all company officers that are applicable to the name change. It is not necessary to

submit a fee with the application, so long as the term of the initial application has not expired, or is not

within 90 days of expiring. Once the Commission reviews the new application, the Vendor will be

notified if further action or additional information is required. The Commission will update the company

name on the website at the conclusion of the review.

F.6 Applicants are required to disclose to the Commission those employees in positions of supervision or

management who are responsible for directly/significantly overseeing, administering or controlling the

provision of goods and/or services to a licensed Maryland casino. During the construction phase,

individuals holding positions with job descriptions such as site superintendents, foremen, project

managers, field supervisors, project supervisors and account representatives are required to be divulged.

During the gaming and hospitality phase, individuals holding positions with job descriptions such as

project managers, regional account managers, sales supervisors and account representatives are required

to be divulged. Each individual is required to submit a Vendor Employee disclosure (refer to H.9) and

submit a notarized Authorization of Release Form.

It is recommended that each every individual listed on H.7, H.8 and H.9 contact the Maryland Department

of Budget and Management’s Central Collections Unit at (410) 767-1220, Monday through Friday, from

8:00 a.m. to 5:00 p.m. to determine if the individual has any unpaid debts to the State of Maryland.



F.7 Vendor applicants are required to attach proof of registration with the Maryland Department of

Assessments and Taxation (MD SDAT) to do business within the State.

Assistance with this process may be obtained from: http://dat.maryland.gov/Pages/default.aspx or by

sending email inquiries to [email protected] if necessary.

The Commission will periodically monitor each Vendor’s compliance with SDAT.

F.8 A Vendor must present sufficient justification to establish that it is suitable for Certification by the

Commission. The burden of proof remains with the Vendor, and the Vendor must continuously maintain

suitability. Failure or refusal to maintain the criteria for approval, to include SDAT “Good Standing”

status, may lead to the Commission suspending or cancelling the Vendor’s Certification.

F.9 The ‘Representative of the Applicant Form’ must be completed and notarized. The Vendor may act as the

Representative of the Applicant or may appoint a Representative of the Applicant to complete and submit

the application. It is the responsibility of the Representative of the Applicant to ensure that the response

to every Commission interrogative is accurate and to ensure that the application is correctly submitted.

F.10 An Applicant should give specific attention to the clear identification of those portions of its application

that it deems to be confidential, proprietary commercial information or trade secrets, and provide

justification of why such materials, upon request, should not be disclosed by the State pursuant to the

Public Information Act (“PIA”), Title 10, Subtitle 6, State Government Article, Annotated Code of Maryland.

Confidential information supplied shall be revealed in the course of the necessary administration of this

application. A blanket statement by an Applicant that its entire application is confidential, proprietary

commercial information or a trade secret is unacceptable. Applications shall be open to public inspection

only after award of a license has been made, to the extent permitted by the PIA. The Applicant is advised

that, upon request for this information from a third party, the Commission will make an independent

determination whether the information may be disclosed. An Applicant or licensee waives any liability of

the State of Maryland, and its employees and agents the Commission, and the Maryland State Lottery and

Gaming Control Agency for any damages resulting from any disclosure or publication in any manner.

When the Agency receives a PIA request, Staff retrieves and compiles all records that are responsive to

the request. “Records” means all papers, emails, notes, recordings, maps, plans, forms, etc. After Staff

compiles all responsive records, the Office of the Attorney General (OAG) reviews the request and the

records, and makes a legal determination as to whether the records may be released. Additionally, when

the Agency receives a request for records of an entity that holds a gaming-related license, or a vendor

registration or certification, Agency Staff or the OAG typically advise the entity of the request and our

anticipated response. The entity may file litigation to prevent the Agency from releasing records it wants

kept confidential.

F.11 Once a vendor is approved by the Commission, the vendor is authorized to conduct business

with all Maryland casinos. The vendor is not required to submit a new application for each casino.

F.12 The Commission may request additional financial and other information as needed.

http://dat.maryland.gov/Pages/default.aspx

mailto:[email protected]



SECTION G - INSTRUCTIONS

These instructions are applicable to any Applicant seeking a Maryland Non-Gaming Vendor Registration or

Non-Gaming Vendor Certification.

G.1 Read each question carefully. Do not leave blank spaces or blank blocks. If a question does not apply,

write “Does not apply” or “N/A.” If the correct answer to a particular question is “None,” write “None.”

G.2 Do not omit or otherwise bypass answers to any response throughout the application. Vendor applicants

who submit incomplete applications may be denied. Refer to F.2 and F.3.

G.3 All entries must be legible, and should be typed or printed with block lettering. If the responses are not

legible, the application may not be accepted.

G.4 The Vendor application must be submitted to the Commission on single-sided paper.

G.5 If additional pages are required in order to answer any question, be sure to indicate the number(s) of the

question(s) being answered and initial each additional page. Refer to G.6

G.6 The Vendor applicant, if an individual, must initial the lower right corner of every page of the application.

If the Vendor applicant is not an individual, the person authorized to complete the form on behalf of the

Vendor (identified on the ‘Affidavit of Representative of Vendor’ form, Page 17) must initial the lower

right corner of every page of the application. The Vendor applicant’s initials signify that each entry has

been reviewed and each entry is complete and accurate.

G.7 The Applicant or the authorized Representative of the Applicant must ensure that every individual listed

on H.7, H.8 and H.9 (Pages 12, 13, and 14) has completed and submitted a Notarized ‘Authorization of

Release of Information’ Form (Page 16).

G.8 The Applicant or the authorized Representative of the Applicant must complete, sign and submit a

Notarized ‘Authorization for Release of Information’ Form on behalf of the Vendor Applicant’s

business entity, listing the ‘Business Name’ on the ‘From’ line. (Page 20).

G.9 The Applicant or the authorized Representative of the Applicant must complete, sign and submit an

‘Acknowledgement and Check List’ (Page 2).



SECTION H - APPLICANT INFORMATION

H.1 BUSINESS NAME OF APPLICANT *

*As written in the Articles of Incorporation, By-Laws, Charter Partnership Agreement or other official documents filed with a State or Federal Government:

______________________________________________________________________________________________

Doing Business As (d/b/a) or Trading As (t/a) Name:

______________________________________________________________________________________________

H.2 APPLICANT’S PRINCIPAL ADDRESSES Describe the Applicant’s use of this address: (check all that apply to this address)

□ Mailing □ Residential □ Corporate □ Production □ Development/Testing □ Warehouse □ Other _____________

Address Line 1

Address Line 2

City

State

Zip

Mailing Address Line 1, if different from above, otherwise enter “Same”


City

State

Zip

Vendor’s website

Describe the Applicant’s use of this address: (check all that apply to this address) □ No Secondary Address

□ Mailing □ Residential □ Corporate □ Production □ Development/Testing □ Warehouse □ Other _____________

Address Line 1

Address Line 2

City

State

Zip



City

State

Zip

Vendor’s website



H.3 APPLICANT’S POINT-OF-CONTACT

*Point-of-Contact: (Name) ________________________________ (Company title) ___________________________ *This individual must either have the authority to make decisions on behalf of the Vendor applicant and/or be on-site at the casino.

E-mail address: _______________________________________________________________________________ All notifications will be made to this e-mail address. If necessary, check the “SPAM” folder for e-mails from “…[email protected]”.

Office telephone Number: _______________________________ Cell Number: ____________________________

H.4 COMPLIANCE WITH MD SDAT REGISTRATION

Maryland SDAT (MD SDAT). Compliance is required (not from the Maryland Comptroller’s Office)

SDAT Department ID Number (1 letter plus 8 numbers): ________________________________________

Circle one: Certificate of ‘Good Standing’ or ‘Trade Name Registration’

H.5 CASINO / CASINO CONSTRUCTION COMPANY ASSOCIATION

Casino / Casino Construction Company with which the Vendor has contracted:

___________________________________________________________________________________________

H.6 COMBINED TOTAL VALUE OF GOODS AND SERVICES

Every vendor applicant shall provide the Commission with the combined total value of goods and services the

vendor expects to provide, or has been contracted to provide, during a calendar year.

The actual contracted value of goods and services will be $ ____________________ * Refer to B.2

. * List an exact contracted $ amount, NOT a range



H.7 VENDOR OFFICER(S), PARTNER(S), AND DIRECTOR(S) Accurately complete all 15 blocks for each individual. Refer to G.1, G.2, F.2 and F.3

Provide information for each Officer, Partner and Director who will be directly/significantly involved in providing goods and services to a licensed Maryland casino.

Last Name First Name Middle Name Suffix (Jr., Sr., etc.)

Occupation Title

Home Address Line 1 Home Address Line 2

City State/Province Zip Code

Social Security Number Date of Birth E-mail address Phone number


Occupation Title




Applicants listed on this page must submit a completed, signed and notarized Authorization For Release of Information (Page 16).

Note: Attach additional copies of this page as needed.



H.8 VENDOR OWNERS Accurately complete all 15 blocks for each individual. Refer to G.1, G.2, F.2 and F.3

Provide information for each person or entity who owns more than five percent (5%) of the Vendor or its business, to include Vendors operating as a General Partnership


Occupation Title





Occupation Title








H.9 VENDOR EMPLOYEE(S) Accurately complete all 15 blocks for each individual. Refer to G.1, G.2, F.2 and F.3

Provide information for individuals holding positions of supervision or management who are responsible for directly/significantly overseeing the provision of goods and/or

services to a licensed Maryland casino. The Applicant shall divulge those individuals who are assigned to manage, administer or control the Vendor’s activities within the

casino, such as project managers, site superintendents, account representatives, field supervisors, distribution managers, sales supervisors, etc.


Occupation Title





Occupation Title








H.10 APPLICANT’S BUSINESS BACKGROUND

(a) DESCRIPTION OF THE VENDOR’S PRESENT BUSINESS. Furnish the Commission with a ‘snapshot’ of the Vendor Applicant’s company and describe the

Vendor’s capacity and capabilities to provide the services declared in the application.

(b) DESCRIPTION OF THE SPECIFIC TYPE OF GOODS OR SERVICES TO BE PROVIDED TO THE CASINO BY THE VENDOR.

(c) NAME OF CASINO(S) TO WHICH SUCH GOODS OR SERVICES WILL BE PROVIDED.

(d) LIST OTHER LICENSED CASINOS SERVED BY THE VENDOR. Provide the Commission with a list of other jurisdictions where the Vendor conducts

business related to a casino operation. ( List the other jurisdictions by Casino Name, City, State, County) .

(e) TALLY OF THE WORK FORCE SUPPORTING THE VENDOR’S PROVISION OF GOODS AND SERVICES TO THE CASINO. Furnish the

Commission with the total number of employees IN MARYLAND who will be directly associated with providing the goods or services to the casino. Furnish the

Commission with the total number of employees OUTSIDE MARYLAND who will be directly associated with providing the goods or services to the casino.

In Maryland =

Outside of Maryland =

(f) DESCRIPTION OF THE VENDOR’S ABILITY TO PROVIDE GOODS OR SERVICES TO MORE THAN ONE CASINO. If applicable, state if the Vendor

is capable of serving one, two, or more Casinos in Maryland and the other casinos with which the Vendor intends to conduct business.




AUTHORIZATION FOR RELEASE OF INFORMATION (INDIVIDUAL)

TO: _________________________________________________________________________________ ( Leave blank - to be filled in by the Commission )

FROM: ______________________________________________________________________________ ( Applicant affiliate’s printed name )

I, the above listed individual, am affiliated with an Applicant who is applying to the Maryland Lottery and Gaming

Control Commission (“Commission”) for a Non-Gaming Vendor Certification. I am affiliated with the Applicant as an:

□ Owner □ Partner □ Director □ Officer □ Manager/Supervisor/Employee □ Other _____________________

The Commission, and its employees, agents, and vendors, is required by law to conduct an investigation of an

Applicant and the Applicant’s officers; partners; directors; proprietors; owners; certain employees; and certain other

individuals affiliated with the Applicant as deemed necessary.

That investigation requires the Commission to collect and evaluate information about me. By executing this

Authorization for Release of Information, I authorize any: Local, State or Federal government unit; commercial or

business enterprise, including a consumer reporting agency, a non-profit entity, an individual or any other public or

private entity, to release to the Commission any and all information about me that the Commission requests. The

requested information may be released in written, verbal, electronic, or any other form.

With respect to any claims or liability arising from the release of the requested information to the Commission, I

expressly waive, release, discharge and forever hold harmless and agree to indemnify, the unit, entity, or individual

that releases information to the Commission, under the authority of this Authorization.

A photo, facsimile, or electronic copy of this signed and dated Authorization shall be equally effective as an

original.

__________________________________________ ______________________________ Signature of Individual Completing Form Date

__________________________________________________ ____________________________________

Printed Name Title

NOTARY PUBLIC

The undersigned, a Notary Public in and for the County of ______________________, in the State of

_______________________, certifies that the above named individual appeared in person, and before me, either known to me

or satisfactorily proven to be the individual whose name subscribed to the within instrument and signed the Authorization and

Notification.

This _________ day of _________________________, 20_____, and to which witness my hand and seal.

____________________________________

Notary Public

____________________________________

Stamp or Seal Printed Name

My commission expires _________________, 20_____



AFFIDAVIT OF REPRESENTATIVE OF APPLICANT

I, _____________________________________ (printed name), am authorized to complete and execute

this Non-Gaming Vendor Certification Application on behalf of the Vendor Applicant (“Applicant”)

_____________________________________ (printed name of the Applicant’s business entity). I am

also authorized to provide all of the information requested on this Form to the Maryland Lottery and

Gaming Control Commission, its employees, agents, and vendors (collectively, the “Commission”), and to

make the representations set forth in this Affidavit.

I have read, and understand, every page of this Application. To the best of my knowledge, information,

and belief, the information that I have provided on, or attached to, this Application is accurate, complete,

and not misleading. I understand that any misrepresentation or omission may lead to the delay or denial

of an application for a Vendor Certification, or may result in the Commission imposing sanctions against

the Applicant, up to and including cancellation of its certification if it has been approved. I understand

that any misrepresentation or omission on this Application may also subject me, or the Applicant that I

represent, to civil or criminal liability. I understand and acknowledge that the Applicant has an ongoing

duty to promptly notify the Commission if any information it provides the Commission changes.

By a separate Authorization for Release of Information, I am authorizing any entity or individual that has

information about the Applicant that I represent, to release that information to the Commission for

purposes of its investigation of an Applicant for a Non-Gaming Vendor Certification.

On behalf of the Applicant and its successors and assigns, I expressly waive, release, discharge, and

forever hold harmless and agree to indemnify, the Commission, the State of Maryland, and their

employees, agents, and representatives, from liability for any and all claims or legal action arising from

any actions that the Commission or the State of Maryland may take related to the collection of information

from the Applicant and the use of that information in connection with investigating a Non-Gaming

Vendor Certification.

______________________________________________ _____________________________

SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE

__________________________________________________ _________________________________________

PRINTED NAME OF AUTHORIZED REPRESENTATIVE TITLE

NOTARY PUBLIC




Notification.


____________________________________

Notary Public

____________________________________





ACKNOWLEGEMENT AND DISCLOSURE

I, the Representative of an Applicant for a Non-Gaming Vendor Certification, understand and

acknowledge the following:

I, ________________________________ (printed name of the Representative of an Applicant), am

applying for a Non-Gaming Vendor Certification on behalf of the Vendor Applicant (“Applicant”)

________________________________ (printed name of the Applicant’s business entity). The

Applicant cannot conduct business with a video lottery operation (licensed Maryland casino) or a video

lottery operation licensee applicant (casino under construction) unless the Commission finds that the

Applicant meets the legal requirements for approval. The Commission, through its employees, agents

and vendors, is required by law to conduct an investigation into the suitability of an Applicant for a

Non-Gaming Vendor Certification.

During the investigation, the Commission is required to collect and evaluate various kinds of

information or reports to determine if Applicants meet the eligibility requirements. The

background investigation will include, but not be limited to, information or reports about the

Applicant’s: character; general reputation; personal characteristics, including honesty and

integrity; financial stability; debts to State agencies; criminal records, records of involvement

with federal, state or other law enforcement agencies as specified in the application, or record of

involvement with any litigation. As a representative, I have the right to request a complete and

accurate disclosure of the nature and scope of the investigation and a copy of a summary of the

Applicant’s rights under federal credit reporting law.

I am requesting that the Commission, through its employees, agents or vendors, obtain this

information about the Applicant to evaluate their eligibility for a license. I acknowledge that this

disclosure and authorization remain in effect during the time the application is pending and

during the time of any Contractor license that may be granted.

By separate Authorization for Release of Information, I am authorizing any entity or individual

that has information about the Contractor that I represent, to release that information to the

Commission for purposes of its investigation of an Applicant for a Gaming Contractor license.

______________________________ _________________________

Signature Date Printed Name

NOTARY PUBLIC




Notification.


____________________________________

Notary Public

____________________________________





CASINO’S CERTIFICATION OF BUSINESS RELATIONSHIP This page is to be completed only by a Casino Rep or an Authorized Casino Construction Rep.

Casino / Casino Construction Company: ______________________________________

Vendor Applicant’s Business Name: ___________________________________________ (Include ‘D/B/A’ or ‘T/A’ Name, if applicable)

The Vendor Applicant (“Applicant”) listed above has entered into a Business Relationship (agreement/

contract) with the Maryland licensed casino or a Maryland casino license applicant listed above. The

Applicant will provide non-gaming goods and/or services with an anticipated value of $ ________________

in a calendar year. The Applicant is required by the Commission to submit a Non-Gaming Vendor

Certification Application since this value either: 1) exceeds $300,000; or 2) the combined total value of non-

gaming goods and/or services to be provided to more than one Maryland licensed casino exceeds $600,000.

The Applicant listed above has entered into a written agreement or contract to provide the following non-

gaming goods and/or services:

_____________________________________________________________________________________

_____________________________________________________________________________________

I, ___________________________________________, representing ________________________________________,

Printed name of Casino Representative - or - Casino - or - Name of company

Authorized Casino Construction Representative

am authorized to complete and execute / sign Business Relationship Agreements on behalf of the Maryland

licensed casino listed as Casino or Casino Construction Company at the top of this form.

Signature of Casino Representative Title within the company Date

-or- Authorized Casino Construction Representative A vendor applicant is prohibited from signing this form.

NOTARY PUBLIC




Notification.


____________________________________

Notary Public

____________________________________





AUTHORIZATION FOR RELEASE OF INFORMATION (BUSINESS)

TO: _________________________________________________________________________________ ( Leave blank - to be filled in by the Commission )

FROM: (Business Name of Applicant) _______________________________________________

The above listed entity (“Applicant”) is applying for a Non-Gaming Vendor Certification in the State of Maryland.

I am an authorized representative of the above listed Applicant.

I understand that the Maryland Lottery and Gaming Control Commission (“Commission”) is required to conduct an

investigation of an applicant for a Non-Gaming Vendor Certification. That investigation requires the Commission to

collect and evaluate information about the entity that I represent. On behalf of the entity, I irrevocably give consent

to the Commission, and persons authorized by the Commission, to: (1) verify all information provided in the license

application documents; (2) conduct a background investigation of the entity; and to have access to any and all

information that the entity has provided to any other jurisdiction seeking a similar license in that jurisdiction, as well

as the information obtained by that other jurisdiction during the course of any investigation that it may have conducted

about the entity.

By executing this Authorization, I authorize any of the following entities to release to the Commission any and all

information about the entity that the Commission requests: local, State or federal government unit; commercial or

business enterprise; non-profit entity; individual; or any other public or private entity. The requested information

may be released in written, verbal, electronic, or any other form.

With respect to any claims or liability arising from the release of the requested information to the Commission, on

behalf of the entity, I expressly waive, release, discharge and forever hold harmless and agree to indemnify, the unit,

entity, or individual that releases information to the Commission under the authority of this Authorization. Photo,

facsimile, or electronic copy of this signed and dated Authorization shall be equally effective as an original.

__________________________________________ ______________________________ Signature of Individual Completing Form Date

My affiliation with the Applicant is: □ Owner □ Partner □ Director □ Officer □ Other ____________________

__________________________________________________ ____________________________________

Printed Name Title

NOTARY PUBLIC




Notification.


____________________________________

Notary Public

____________________________________



Maryland Non-Gaming Vendor applicants Pay Careful ... · If a Vendor has three contracts, one at...

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